By Terri A Lewis, Ph.D.
Editor’s Note: When the CDC announced its new voluntary guideline for opioid prescribing, the National Pain Report turned to one of our frequent contributors, Dr. Terri Lewis. She studies (and comments) on the U.S. health care system. As a daughter and mother of chronic pain patients, she has written on access and quality issues. Here’s her reaction to the CDC announcement:
Where to begin?
These guidelines are predicated on the notion that pain should be addressed differently based on whether it originates in a cancer diagnosis, which then supposes the necessity for palliative care models. That is a faulty heuristic. There is no functional difference in chronic pain that originates from any source. Our biology imposes chronic pain as an organic adaptive response to injury or illness. Imposing the label gives us permission to withhold palliative treatment from one group over another, which is not ethical. In fact there are almost no conditions of chronic pain that will not be present at the death of the individual; cancer is not the arbiter for length of life.
The damage caused by the politicization of treatment for chronic pain and co-mingling of treatment approaches with addiction models has already been accomplished – the damage is done. Walking this back will be very difficult as states are already passing laws and regulations that impose practice restrictions on primary care physicians. In some cases these are so burdensome and onerous that PCPS are refusing to serve or take on new patients with chronic pain. Patient dumping is occurring as we speak.
The guidelines and state laws provide us with directives that have no measures of effectiveness. The evidence for their application is admittedly of low quality – applying GRADE criteria to low quality evidence does not make a silk purse out of a sows’ ear. As written, we cannot know whether they will achieve their intended effect for reducing overdose deaths – which seems to be the primary concern. There is no way to determine whether a reduction in prescribing will lead to better patient outcomes except through monitoring and case investigation – which our scientists at CDC are loath to do. So we are still left with the very significant problem of developing evidence for the effectiveness of these regulations. The only way I see to get past this one is for patients to take control of their data and conduct their own research.
This is a tremendous opportunity to learn on many levels. The question is whether the risks to patients outweigh the benefits to the public at large. There is almost nothing that is less fruitful or fair than forcing persons who have grave pain related conditions to live without effective care. Is suicide more publicly acceptable when conducted by methods other than opiates? What about the ongoing family stressors imposed by caring for a loved one who is underrated for their chronic health condition? We already know how family health is negatively magnified by stressors that increase and hasten the onset of stress related disease processes.
Is this an acceptable trade-off?
Time will tell how we truly value the projected outcomes. It shouldn’t take too long for results of these policies to reveal themselves.
Follow on Twitter: